Endeavor has been made to attribute icterus neonatorum, in accord with the extensive experiments of Stadelmann, Affanassiew, Tarchanoff and others, to a polycholia or more correctly a pleo chromia, which arises as the result of the destruction of countless erythrocytes during the first days after birth (Hofmeier, Silbermann, and others). However, the supposition that during the first days of life there is an extensive disintegration of red cells has been refuted and with this refutation the hypothesis of a pleochroic icterus becomes untenable.
Investigations have shown that the blood of the newborn is, at birth, richer in corpuscles and lnemoglobin than that of the adult. A count of six to seven million erythrocytes in a cubic millimetre is not uncommon. This count sometimes increases, during the first two or three days of life and then falls (Lepine, Hayem, and others). The ex planation of this has already been given by these writers. The increase and decrease in the number of cells is only apparent and is brought. about by variations in the quantity of the blood plasma. Cohnstein and Zuntz furnished the experimental proof.
In nursling animals showing variations in the number of cells per cubic millimetre, similar to those of newborn children during the first days of life, determinations of the total number of red cells have indi cated that their number increases from the first day of life but never decreases. Microscopic examination and the determinations of the re sistence of the red cells have shown, contrary to Silbermann, the absence of the products of red cell destruction (Fischl, Knopfelmacher).
The destruction of red cells in the newborn has also been connected with the "physiological transfusion" which every newborn experiences at birth. At birth a. large part of the blood present in the placenta is expressed into the fastus: and when the cord is tied off late, this amount is further increased (according to Budin by about 90 Gm. or 3 oz). This superfluous blood is said to he destroyed during the first days. Hof meier endeavored to verify this hypothesis by metabolism experiments. As far as the erythrocytes are concerned, it has been established that they are not destroyed in abnormal numbers.
Two other peculiar theories rest on the assumption of a tion of blood corpuscles in the newborn. Silbertnann advanced the one the destruction of the erythrocytes is supposed to lead to 'ilia," through this to capillary stasis and thromboses in the liver, and thus to icterus. Such thromboses, however, have never been found, not even by Silbermann himself. With this, Silbertnann's theory also falls. Recently Leuret has affirmed anew the destruction of red cells in the newborn. It is supposed to occur in consequence of the cooling of the skin after birth. Through this, as in paroxysmal lnumoglobinuria, there arises a turinoglobimemia. Leuret found this but no one else has. The haemoglobin in the circulation is changed, in the tissues, to a yellow coloring matter. Since, however, a hannoglobintemia does not exist in the newborn, the hypothesis of Leuret must also be rejected.
Endeavor has also been made to connect the icterus with a post partum fall in the blood pressure (Frerichs). This assumption, however
falls, since icterus is especially intense in asphyctic children and those with pulmonary atclectases; and in these affections the blood pressure is increased.
Not more fortunate is the assumption of a compression of the gall ducts by the dilated liver veins, distended in consequence of the afore mentioned transfusion. Histologic examination of the liver in the new born shows the gall-capillaries not compressed but on the contrary much dilated (Abramow); my own observations have also taught me this fact. In preparations in which the bile-capillaries are demonstrated according to the method of Eppinger, one sees them mostly varicose and tortuous, as an expression of the extreme fulness of the gall-duct sys tem; and moreover this is present immediately after birth and in those still-born.
In reconsidering the remarks concerning these various theories, we are forced to the conclusion that up to the present time no single theory is fully compatible with the facts. Icterus neonatorum in this respect resembles the icterus occurring with infectious diseases and with sepsis in which, similarly, the anatomical examination of the liver gives no explanation of the resorption of bile.
In order to make the passage of the bile over into the blood com prehensible, in such cases, one can assume with Minkowski, Lieber meister and others, that we are dealing with a functional secretory anomaly of the liver cells; according to Minkowski, in such eases the liver cell has lost the faculty of sending the bile-pigment and biliary acids into the gall-ducts alone and gives these substances up to the blood-capillaries also. According to Pick, the bile is directed into the lymphatic system. According to Abramow, an increased secretion of bile gives rise to this secretory disturbance; the liver cell produces bile profusely but its excretory energy is not able to overcome the abnor mally high pressure in the bile-capillaries and consequently the bile is turned into the blood-capillaries by the cell. The overloading of the blood-capillaries, the passive congestion, are the causes for the assumed functional disturbance of the liver cell, which Abratnow terms "asthenie polycholia." It is my belief that the causes of icterus neonatorum lie in the over filling of the bile-capillaries in the fcvtus, with rather tenacious bile, and in the lively production of bile by the liver cell immediately after birth, in consequence of the rich supply of blood. The newly-formed bile cannot flow out through the over-filled bile capillaries and, therefore, passes from the liver cell into the blood-capillaries. Accordingly, icterus neonatorum is a physiological manifestation. It offers the most favor able prognosis and leads to no complications. The statement that it. exerts an effect on the general health of the child, has not yet been sub stantiated. It has been stated (Schaeffer) that intensely icteric chil dren especially lose weight during the first days of life. It is possible that a considerable resorption of bile and Hilary acids can be held responsi ble for this.
intervention in cases of icterus neonatorum is in no sense indicated.